A spotlight on neglected hepatitis

On World Hepatitis Day, Dr Philippa Matthews, a Wellcome Trust Clinical Research Fellow, puts the spotlight on neglected viruses including hepatitis B and hepatitis C.

Some infections are good headline-grabbers – and alongside headlines, come education, engagement, investment, advocacy and action. On the global stage, these diseases include malaria, tuberculosis and HIV, and at home we are made aware of ‘hospital superbugs’ like MRSA, while periodic outbreaks of influenza or meningitis might make the front pages. International headlines occasionally become dominated by epidemics, like the Ebola outbreak in West Africa in 2014-2015. It is easy to see why these grab public attention, either as a result of the numbers of people affected, the severe disease that results, or the associated emotional responses which range from anger to intrigue and fear.

However, other important pathogens never make it onto this list of ‘big hitters’, and viral hepatitis infections fall soundly into this group. Why does this group of viruses not have a clear public profile and what can we do about it?

However, other important pathogens never make it onto this list of ‘big hitters’, and viral hepatitis infections fall soundly into this group. Why does this group of viruses not have a clear public profile and what can we do about it?

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are two viruses that together account for over 300 million infections worldwide. Despite being unrelated, both viruses target the liver, and both are blood-borne, meaning that they share transmission routes – including mother-to-child (usually around the time of birth), through contaminated needles, surgical equipment or transfusion, via tattoos, piercing and circumcision, or through sexual contact. In some instances a good immune response leads to the infection being cleared, but in others (especially those exposed in childhood), the virus persists and becomes chronic. It is these long-term infections that lead to ongoing inflammation, leading to scarring of the liver, and ultimately to liver failure and cancer. Untreated chronic Hepatitis B has been described as a carcinogen as potent as cigarette smoking, and the virus is thought to account for approaching 1 million deaths every year. Despite this, there is a lack of information and education, and hepatitis viruses attract substantially less funding compared to other public health problems of a similar magnitude.

These viruses have accompanied Homo sapiens through hundreds of centuries of evolution; perhaps this is a reason why the infections are so deeply entrenched in our populations, and also explains why they fail to make headlines: what’s new? Despite the severe disease that can potentially result, the viruses are also often silent, meaning an individual can live for many years – and potentially a lifetime – without being aware of their infection. Those with infection are further silenced by poverty, lack of education, absence of political agenda and investment, under-resourced clinical services, and stigma.

Those with infection are further silenced by poverty, lack of education, absence of political agenda and investment, under-resourced clinical services, and stigma.

Strong taboos can accompany chronic viral infection; diagnosis of hepatitis infections may have profound consequences on social and personal relationships, accommodation, employment and income, so individual stories and experiences remain hidden through shame and through fear.

The good news is that we have a range of strategies through which we can tackle these infections; for HBV we have a vaccine to prevent infection and drugs that can suppress the virus, while for HCV, new drugs that can cure infection in the vast majority of those with the virus. HCV cure is a treatment revolution that truly deserves celebration. Keeping individuals informed about their condition, and providing careful clinical monitoring over time is important, even for those not on treatment. Breaking down stigma is not easy, but can be done through consistent educational messages, frank communication, social and clinical support networks, and responsible involvement of media, governments, NGOs and patient groups. Political resolve is increasing, and is underpinned by a clear statement enshrined in United Nations ‘Sustainable Development Goals’ that we should aim for the elimination of viral hepatitis as a public health threat by the year 2030.

So what’s missing? The answer is that we offer these important interventions to only a tiny proportion of those who need them. HBV vaccine is an established part of international vaccination programs given in childhood, but many infants still get missed, and the intervention will only gradually make an impact on the frequency of infection across whole populations. For both HBV and HCV, the individuals who have actually been diagnosed with infection represent a small fraction of the total pool of those who carry the viruses. Of those who are aware of their infection status, only a small proportion are able to access clinical care, fewer still are offered appropriate, sustainable and affordable treatment, and only a subset of these go on to a successful outcome of viral suppression or complete clearance. We are currently providing high quality clinical care to patients at the very tip of an enormous iceberg.

World Hepatitis Day is a crucial opportunity to celebrate the remarkable successes of vaccination and new therapeutics, and to make sure we educate our communities about the importance of these.

World Hepatitis Day is a crucial opportunity to celebrate the remarkable successes of vaccination and new therapeutics, and to make sure we educate our communities about the importance of these.

We should also be loud advocates for diagnosis, encouraging people to access testing so they can take action to seek treatment and to protect their families. Tackling this has to be underpinned by an awareness of the stigma that can still exist around this group of infections, and by recognizing this as a potent barrier to both diagnosis and treatment. Stigma and social taboos are complex and deep-rooted, but are universally perpetuated by lack of clear and consistent information, so let’s also use World Hepatitis Day as a platform to talk openly, to provide education and resources, and to dispel fear.

Finally, there remains an urgent need to find a vaccine that protects against HCV infection, and to develop curative therapy for HBV to tackle the huge global burden of chronic infection. To do this requires commitment from government, pharma, public health, research and clinical care; my hope for World Hepatitis Day is that we can start to harness many voices to prompt decisive action. If we can make headlines, then we know that education, engagement, investment, advocacy and action can all follow.

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